1. Introduction

In Southeast Burma (Myanmar)[1], civilians are struggling to get essential healthcare, amidst an ongoing human rights and humanitarian crisis since the 2021 coup[2]. The indiscriminate and direct attacks perpetrated by the Burma Amy[3], under the command of the State Administration Council (SAC)[4], have caused significant loss of life and injuries. This situation is worsened by limited access to medical care due to the ongoing conflict, SAC attacks on clinics and healthcare workers, shortages of medicine and supplies, transportation challenges, and the SAC denial of lifesaving humanitarian aid; whilst local villagers and community organisations persevere to deliver lifesaving care. Villagers’ right to health care is being denied, highlighting the urgent need for improved medical protection and international action to halt SAC’s attacks.

This briefing paper presents evidence of the various healthcare challenges reported by villagers and documented by KHRG from January to October 2024 in locally-defined Karen State[5], detailing the difficulties villagers experienced in accessing treatment and medicines throughout Southeast Burma. The paper starts with an overview of the situation of human rights in Southeast Burma, and the crisis since the 2021 coup. The following section presents villagers’ concerns and experiences over the past ten months regarding access to healthcare amidst constant military attacks and displacement. The last section provides a legal analysis of the situation of the right to healthcare in Southeast Burma for this past year, followed by a set of policy recommendations for local and international stakeholders.

2. Contextual overview: a human rights and humanitarian crisis
Human rights violations in Southeast Burma 

Armed conflict and mass human rights violations have been ongoing in Southeast Burma since the country’s independence in 1948. Starting in the 1960s, the Burma Army utilised the ‘four cuts’ strategy to combat armed resistance by cutting off food, funds, intelligence, and recruits through targeting every person and village thought to have connections with the Karen National Union (KNU)[6]. Abuses from the Burma military included grave human rights violations committed against villagers, such as extrajudicial killings, torture, arbitrary arrests, forced displacement, forced labour, and sexual violence, amounting to war crimes and crimes against humanity.[7]

Since the 2021 coup, the SAC has intensified attacks on civilians in Southeast Burma through by reinvigorating the ‘four cuts’ strategy.[8] Unlike past counterinsurgency operations mainly conducted by land, the SAC has now unleashed relentless and indiscriminate air strikes, which destroy villagers’ houses and farmlands.[9] Air and ground attacks target civilians and armed resistance fighters alike.

Historical context: access to healthcare in Southeast Burma

In 1956, the KNU established the Karen Department of Health and Education, the precursor to the Karen Department of Health and Welfare (KDHW)[10], to provide primary health care across locally-defined Karen State.[11] Throughout the years of military conflict and attacks, access to healthcare for villagers was deliberately denied by the Burma Army’s ‘four cuts’ and imposed restrictions on freedom of movement and the trading of medical supplies in the 1990s and 2000s.[12] Since then, the KDHW and many community-based partners deliver comprehensive healthcare across Southeast Burma, including conflict-affected areas, offering free or low-priced treatment. In tandem, Burma government-run hospitals have been set in the main big cities in the region, although villagers reported higher costs for treatment and disrespectful and discriminatory attitudes from Burma government staff, including an arbitrary denial of treatment.[13]

Before the 2021 military coup, challenges already existed to access healthcare in rural areas, due to poor road infrastructure and a shortage of medical facilities and trained personnel. While clinics managed by KDHW, the Burma government, or NGOs were available, they often lacked sufficient resources, medicine, and healthcare workers, limiting their ability to the treatment of mild conditions. Serious medical cases had to be referred to Burma government hospitals, or patients were sent across the border and into Thailand.

Accessing healthcare since the 2021 coup

Since the 2021 military coup, the healthcare system in Southeast Burma has been pushed into a crisis, with rural ethnic areas being the most affected due to reduced available services.[14] Attacks from the SAC have severely injured many villagers, who struggle to access prompt and adequate medical treatment. The situation is worsened by the security risks faced by both injured villagers and healthcare workers when seeking or providing medical care. The SAC has also imposed heavy restrictions on transporting medical supplies and increased military checkpoints. Some displaced villagers receive healthcare from border organisations, but most internally displaced persons (IDPs) and rural villagers face inadequate healthcare, exacerbated by rising health issues, including COVID-19. Many are left with no option but to try to treat themselves. Travel restrictions and resource diversion to more heavily conflict-impacted areas have further diminished rural services.[15] 

As armed conflict and SAC air and ground attacks escalate, local healthcare workers have set up mobile clinics and outreach programs for vulnerable populations in displacement sites. Some free emergency healthcare support is available along the Thai-Burma border, delivered by KDHW in collaboration with Back Pack Health Worker Team (BPHWT)[16], Mae Tao Clinic and the Burma Medical Association (BMA), providing healthcare support mainly to displaced villagers. In remote areas, doctors taking part in the Civil Disobedience Movement (CDM)[17] have also been training villagers to treat patients and have been delivering healthcare.

3. Factual summary: barriers to obtaining healthcare in Southeast Burma

Since the 2021 coup, villagers in Southeast Burma have faced severe health threats due to ongoing armed conflict and State Administration Council (SAC) attacks. From January to October 2024, KHRG received reports of at least 21 villagers being killed, including five children, and 73 villagers injured, including 21 children, by military attacks, including landmines, and SAC shelling and air strikes. As documented during 2024, attacks on villagers’ safety and health are worsened by the SAC’s destruction of clinics and threats to healthcare and humanitarian workers, as well as SAC imposed travel restrictions and confiscation of medicines at checkpoints. Villagers try to avoid roads with SAC checkpoints and hence are forced to use longer, more inaccessible routes when transporting medical supplies and patients. Many have lost their lives while trying to reach equipped clinics on time. When displaced in the forest, villagers face additional health challenges (especially elderly people, children and pregnant women) and their access to medicines is even lower –exacerbated during the rainy season. Villagers in Southeast Burma are denied their right to health by the SAC and struggle to survive during this SAC-made healthcare crisis.

This section highlights the various challenges that villagers in Southeast Burma have faced in accessing healthcare during the past ten months (January to October 2024), based on 94 related field reports, including audio interviews, situation updates, incident reports, and short updates, documented by community members trained by KHRG to monitor the human rights situation in their communities.[18] Reported challenges to the right to health include (a) attacks on hospitals, clinics, and healthcare workers by the SAC, (b) gaps in available healthcare services and lack of medicines and medical supplies, (c) travel restrictions, inaccessible routes to medical facilities, and confiscation of medicines, (d) displacement, leading to an additional crisis, and (e) lack of mental health services. Throughout this section, villagers’ struggles and local efforts to cover such gaps are also presented.

a) Attacks on hospitals, clinics, and healthcare workers 

In 2024, the SAC continued to conduct attacks on civilian areas, destroyed hospitals and clinics, and threatened healthcare workers in Southeast Burma. These attacks create significant difficulties and challenges for civilians, who rely on these facilities for healthcare, rendering them unsafe and inaccessible.

     Unsafe villages and clinics:

SAC attacks on villages and hospitals create devastating impacts on villagers’ access to healthcare. For instance, on February 2nd 2024, at around 8 am, SAC police officers and soldiers from Light Infantry Battalion (LIB)[19] #603, based at Ta Poo (Leik Tho) Town, Daw Hpa Hkoh Township, Taw Oo District, fired mortar rounds into Ta Poo’s Section #Aa---, following an armed resistance attack on that day at the police station. A villager named Saw[20] A---, from Leik Tho Section #Ab---, explained: “Many houses were hit by the mortar rounds fired from the police station. […] Houses near the police station were hit as well as a hospital.” The shelling severely injured three villagers including a boy from Ta Poo Section #Aa---. As the hospital was not safe, and partly destroyed by the shelling, villagers were not able to access medical treatment in their town, and had to travel to Toungoo Town or Si Poo Town. 

A similar situation was reported in May 2024 in Dooplaya District, by a village head from Ac--- village, Kaw Wa Leh village tract, Kyoh Doe Township, named Saw B---: 

“There is a hospital [in Kruh Tuh Township]. If pregnant women give birth and people [need to] go for an operation, they go to the hospital. The healthcare workers provided medicines and asked patients to go home with medical instructions to follow. Patients dare not stay at the hospital because shelling landed at the hospital [on April 11th 2024].”

Despite needing immediate medical attention, ongoing SAC shelling and air strikes force villagers to flee, disrupting treatment. In one instance, on June 25th 2024, at about 8:30 pm, SAC Artillery #310 under Light Infantry Division (LID)[21] #44 fired three 81 mortar rounds onto Ad---  village, Hka Yweh village tract, Kyeh Htoh Township, Doo Tha Htoo District. During this attack, a village named Ma[22] C--- (21 years old) was killed and Ko[23] D--- and his 11-year-old daughter named Ma E--- were injured. After the incident, Ma E--- was sent to a nearby clinic to treat a severe injury on her thigh. A medic from an armed resistance group treated Ko D---’s injury. While the medic was stitching up his injuries, shelling was conducted again by the SAC, and they had to flee to Ae--- village and complete the treatment there. In fear, villagers from Hka Yweh village tract displaced from their villages.

Saw G---, a displaced villager in Ag---  village, Noh T’Kaw Township, Dooplaya District, explained the difficulties in accessing healthcare in areas with SAC presence: 

“Sometimes we had sick patients who were about to die, we wanted to send them to the hospital, but we couldn’t because Burma [Army] soldiers were living in the hospital. During the daytime, they [Burma Army soldiers] allowed us [civilians] to send patients [to receive treatment at the hospital]. But at nighttime, patients were forced to go home.”  

     Medical facilities destroyed by SAC attacks:

As villagers rely on clinics and hospitals for healthcare, it becomes extremely difficult to obtain treatment after SAC attacks destroy the facilities. During the reporting period (January to October 2024), at least four medical facilities were destroyed by SAC attacks.[24] 

Reportedly, in some instances, the SAC intentionally destroyed hospitals following attacks by armed resistance groups. A villager named H--- from Ah--- village, Saw Khay area, K’Ser Doh Township, Mergui-Tavoy District, who experienced an SAC air strike on May 8th 2024 in Ai---village, K’Ser Doh Township, explained: “Aj--- Hospital was destroyed too when the air strike took place in Ai--- village. This was a newly constructed hospital [administered by the SAC] which has never been used [properly] yet. I heard [some] soldiers from the armed resistance groups received treatment at the hospital after the seizing of the SAC army camp. When the SAC conducted the air strike, there were no people inside of the hospital. The SAC heard the news that soldiers from armed resistance groups received treatment at the hospital. There, the hospital was destroyed.” [25] The SAC air attack occurred after Karen National Liberation Army (KNLA)[26] troops captured the SAC’s Pe Det army camp, located on the Mergui-Tavoy road (about 50km away from the incident place).

      Attacks on healthcare workers:

It is dangerous for aid providers and healthcare workers to deliver support to areas affected by armed conflict due to SAC air and ground attacks. While crossing SAC checkpoints, healthcare providers are also at risk of arrest if they are caught carrying supplies.

Saw I---, a local leader from Am--- village, Tha Kyat village tract, Ta Naw Th’Ree Township, Mergui-Tavoy District, who accompanied healthcare workers to An--- village, Ba Wa village tract, Tannitharyi Township, Mergui-Tavoy District, to provide medicines and healthcare, reported: “There was one main difficulty for us passing the road because there was a group that we had to be afraid of: the SAC [personnel] that operates in that area. They [SAC] have checkpoints. […] When we went there, we did not pass the checkpoint. We used the ‘thieves’ [hidden] road’ to get into the village. We were going to the village just like thieves. We had to get there through the jungle road, in difficulties.” He added: 

“There’s an SAC base there. It would not be easy for us, if they knew that we are carrying medicines. […] They [the SAC] knew that PDF [People’s Defence Force[27]] are present in Ba Wa area. That’s why they would not believe it even if we told them we are bringing the medicines for the villagers. […] If the SAC found out about it [the delivery of medicines], we are less likely to survive.” 

On August 30th 2024, when going to send medicines to flood-affected villagers, this group of healthcare workers were attacked by the SAC on the way, near An--- village. Saw I--- added: “We went there during the flooding month. They conducted mortar rounds at us when we were going to the village. Healthcare workers from KDHW and Backpack [Back Pack Health Worker Team] also went together with us during that time.” 

b) Lack of available healthcare services, healthcare workers, and medical supplies 

Although accessibility challenges existed before the 2021 coup, frequent SAC attacks on civilian areas and mass displacement leave (the limited) functioning hospitals and clinics far from those in need. Severe shortages of medicines and supplies, often due to confiscation and attacks by the SAC at checkpoints, and high costs of treatment for severe injuries, compose the already dire situation.

     Lack of available healthcare services:

It is challenging for villagers to seek medical attention when they are sick or injured as, most of the time, healthcare workers also flee because of SAC attacks on villages. A displaced villager named Naw[28] J--- from Ao--- village, Khaw Hpoh Pleh village tract, Bilin Township, Doo Tha Htoo District, reported on SAC air strikes that happened on April 29th 2024, at around 11:30 pm, in Ao--- village, that destroyed schools, the church and houses, injured a villager, and left many displaced. Regarding the access to healthcare, Naw J--- said: 

“It’s very difficult. When people need medical attention, we have to look for doctors or nurses who have also run away and are sleeping [displaced] elsewhere.” 

Villagers also face difficulties when they do not have trained healthcare workers in the village and have to rely on midwives to take care of their health. A villager named Saw K--- from Di--- village, Day Loh area, Taw T’Htoo Township, Taw Oo District, said: “When villagers are sick, there is a midwife in the village taking care of the patients. It’s just for the common illnesses. When villagers have to undergo surgery, it’s difficult because of the difficulty in transportation [to equipped hospitals]. In terms of undergoing surgery, it costs money, so villagers are in debt [when they undergo surgery].”

Villagers injured by SAC air strikes or shelling faced difficulties travelling to get treatment. When a villager named L---, from Aq--- village, Than Taung Gyi Road, Taw Oo District, was hit on the face by shrapnel for SAC mortar shelling on October 7th 2024, his family removed the shrapnel piece with a nail clipper and treated him at home. The villager developed a fever and had to stay in bed. Similarly, another villager named Saw M--- from Ar--- village, Saw Muh Plaw village tract, Lu Thaw Township, Mu Traw District, explained:

“We are not close to the clinic and hospital. There is a pharmacy or clinic, but it is located far from our area. If our children are sick, we have to access healthcare services [located] far, and it is not adequate […]. There are no medicines prepared for common diseases. Some people experienced delays in accessing treatment and passed away.”

The severe increase in injured villagers due to SAC attacks and ongoing conflict also puts a strain on the delivery of adequate healthcare.

Local efforts have increased to solve the lack of adequate treatment: for instance, with the unavailability of healthcare services to treat patients who need emergency surgery and to assist pregnant women giving birth, local leaders in Hpa-an District collaborated with the BPHWT and KDHW and established a surgical treatment site in As--- village, Naung Khwi village tract, Paing Kyoh Township, Hpa-an District, in June 2024.

Villagers are adopting different agency strategies to care for patients. Villagers from At--- village, Ha T’Reh village tract, Hpa-an Township, Doo Tha Htoo District, attended medical training provided by Thara[29] N--- (a Karen healthcare worker from an unknown organisation) providing care in Av--- village, Kruh Kyee village tract, Hpa-an Township. A local midwife named Naw O--- reported: “If illness occurs in the village, the healthcare workers who attended medical training from the Thara [N---] take care of the patients. If their sickness is serious, the patients are sent to the hospital. The hospital is in Av--- village. CDM healthcare workers who participated in the CDM dare not return to the town and they take care of the patients there. There is a makeshift basement where they take care of the patients. They have become clinics under the KNU administration.” 

Some villagers also relied on CDM healthcare workers to receive treatment. U[30] P---, a village head from Aw--- village, Za Yat Gyi Tuang Chan village tract, Htaw Ta Htoo Township, Taw Oo District, who is also responsible for the emergency relief response in Z’Yat Gyi Taung Chan village tract, stated: “There are also [Burma government] healthcare workers participating in the CDM. These CDM health workers support in taking care of the civilian’s health in any way that they can, during this time [since the 2021 coup].”

Villagers also refer patients to hospitals across the border, in Thailand, where they can access equipped and prompt treatment.[31]

     Lack of medicines and medical supplies:

Amidst the escalation of armed conflict, medicines are often unavailable. For instance, on March 5th 2024, a 12-year-old villager named Ma R--- from Bc--- village, Pyi Gyi Ma Naing village tract, Bot Pyin Township, Mergui-Tavoy District, was seriously injured from stepping on a landmine planted by SAC LIB #560 while she was foraging ‘dog fruit’. Due to the landmine explosion, her left foot was broken and her body was also injured. One of the local villagers from Bc--- village reported: “We [local villagers] took her [the victim] and sent her to Bd---- hospital. As the hospital [Bd---- hospital] didn’t have adequate medical supplies, we sent her to receive treatment at the Burma Army camp in Bot Pyin Township, at around 3 pm”. Similarly, Ma S---, a villager from Be--- village, Th’Pyay Nyun village tract, Moo Township, Kler Lwee Htoo District, was sent to a hospital in Yangon for treatment after being seriously injured by the shelling conducted by SAC IB #73 on August 5th 2024. She initially went to Bg--- Hospital, but the hospital lacked adequate medical supplies to treat her injuries.

In Tanintharyi Township, Mergui-Tavoy District, the healthcare system is managed by the Karen Department of Health and Welfare (KDHW) and there are also private self-funded clinics that villagers rely on. However, healthcare workers from these medical facilities face severe challenges, including medicine shortages and transportation restrictions, and need to smuggle medicines from Thailand. Similarly, in Kler Lwee Htoo District, Ler Doh Township, a healthcare worker explained:

“We don’t have enough medicine or other materials, like X-ray machines, to assess patients’ conditions. We need support from others to help us provide adequate treatment for patients.” 

The situation is the same in Moo Township, where many have to order medicine from the town secretly, and sometimes ask women to go to the town and retrieve medicines as some consider it is easier for them to talk to SAC soldiers and negotiate on the way, when crossing checkpoints.

     Unaffordable costs: 

Struggling to secure amidst the conflict and constant attacks on villages and plantations, some villagers cannot afford medical fees when they need to seek medical attention due to sickness or injury. As explained by a 18-year-old villager, T---, who was injured on January 8th 2024, by mortar rounds fired by SAC Infantry Battalion (IB)[32] #39 into Bi--- village, Seik Hpoo Tuang village tract, Htaw Ta Htoo Township, Taw Oo District: “The mortar round fell next to me when I was sitting, and I was injured. I was hospitalised [at Bj---  General Hospital]; they provided the treatment, but they did not take the shrapnel out from my body. […] They haven’t taken the shrapnel out yet [as of February 2024]. […] They told me to go back to the hospital when my wound hurt. I have already been to the hospital three times and the cost is expensive so I could not go [anymore].” T--- was injured on his waist as he went to work at Bi--- village. An elderly person from Bi---  was also injured due to the shelling. 

Villagers who need treatment at hospitals in towns often cannot afford treatment costs. According to another villager named Naw V--- from Bk--- village, Kaw Baw village tract, Ler K’Hsaw Township, Mergui-Tavoy District: 

“Some people cannot afford their children’s [medical] treatment. The clinics are also far. The price of medicines also increased. When the price tripled, villagers were facing serious problems.” 

Because of the ongoing conflict, scarcity of supplies, and difficulties to travel, the price of commodities have increased, including medicines, so civilians who are daily wage laborers have difficulties to purchase them.

Villagers who can access treatment in KNU-administered hospitals face less financial burden, as treatment there is free or has a low cost. Ma W--- (14 years old), from Bl---  village, Nat Than Kwin village tract, Moo Township, Kler Lwee Htoo District, was seriously injured on both of her legs, and lost her right leg, due to a landmine explosion in Bl---  village, on May 29th 2024, planted by SAC troops inside her village. After the incident, KNLA soldiers sent the victim to a KNU-administered hospital in Hplee Hta village tract, Moo Township. Regarding the treatment at the hospital, Ma W---’s uncle, U X---, explained: “Now, I don’t know about the treatment cost yet. The medics at the clinic understand us [their financial difficulties] and mostly they will help civilians [treat them for free]. They [the victim’s parents] face difficulties, as their family [’s financial] condition is not that stable. I told them [the victim’s parents] not to feel down and told them that the doctors will understand us.” [33] The victim’s parents are daily wage labourers.

c) Travel restrictions, inaccessible routes, and confiscation of medicines

During the ongoing armed conflict, villagers also face travel restrictions imposed by the SAC as well as fear of crossing SAC checkpoints. To avoid such risks (and due to the shortage of functioning clinics), villagers have to travel long distances, through inaccessible roads, to reach equipped healthcare services. Some injured villagers have lost their lives while trying to receive care.

     Travel restrictions imposed by the SAC:

Since the 2021 coup, the SAC has imposed a curfew in many areas in Southeast Burma impeding villagers to travel at nighttime. Such restrictive measures can become deadly. On May 6th 2024, at 4:52 am, SAC Artillery Unit #310 fired mortar rounds that landed on a rubber plantation in Bm--- village, Zee Pyaung village tract, Kyeh Htoh Township, Doo Tha Htoo District, severely injuring a villager named Saw Y---, while he was working. As soon as he was injured, local leaders sent him to a nearby clinic in Kyauk Pyar area. However, there were no blood units available for transfusion. As the SAC enacted curfew only allows villagers to travel after 6 am, it was not possible to send the patient to the nearby SAC-administered hospital in Thein Z’Yat Town. Local leaders communicated with KDHW staff from Kyeh Htoh Township and sent the patient to Hpa Lan Taung Hospital[34] in Hpa-an Township instead, located further away. Although Saw Y--- arrived at Hpa Lan Taung Hospital to receive treatment, he passed away on May 7th 2024, shortly after his arrival.

Villagers have also reported the SAC not allowing the construction of roads to facilitate transportation. Saw Z---, a village committee member from Bn--- village, Kaw Ler village tract, That Htoo Township, Doo Tha Htoo District, said: “We face challenges because no healthcare workers and medical supplies are available in our village. […] It is because we do not have clinics or health workers, and [have] difficult transportation [as the village is in the middle of two rivers]. The Burma Army [SAC] does not allow us to build a bridge to make our transportation easier. One day, when we were building a bamboo bridge, they [SAC] shelled six mortar shells [in the area]”. When villagers are sick or injured in Bn---  village, they are taken to the village tract clinic in Kaw Ler village tract, facing many challenges without accessible routes.

     SAC checkpoints:

Villagers expressed fear of crossing SAC checkpoints when trying to access healthcare. SAC soldiers at checkpoints not only scrutinize and sometimes confiscate their belongings but also arbitrarily demand money. The introduction of the Conscription Law in 2024 by the SAC has further heightened fears among middle-aged villagers of being arrested. A villager named Saw Do--- from Bo--- village, Day Loh Muh Nu area, Htaw Ta Htoo Township, Taw Oo District, reflected: 

“In terms of healthcare, going to the hospital, we face difficulties in transportation. We have many things to worry about. […] They [villagers] cannot travel anytime they want during the nighttime. […] There are checkpoints on the way. Now, there is a conscription law [enacted by the SAC]. [Therefore,] young people have more fear [to cross SAC checkpoints]. They have to send food to the hospital [for patients] back and forth. That creates anxiety and young people have to travel in fear. […] We worry that they [SAC at checkpoints] would target young people.” 

Another villager, Naw Dp--- from Bp--- village, Khaw Hpoh Pleh village tract, Bilin Township, Doo Tha Htoo District, reported: “For serious cases, such as giving birth, we have to go to Bq--- hospital. Sometimes, transportation goes well, but other times, we face difficulties, such as checkpoints on the way, and we need to contact the doctor to check whether they are at the hospital or not.”

For the civilians living in Ler K’Hsaw Township area, Mergui-Tavoy District, the situation worsened from November 2023 to February 2024, as explained by a villager from Br--- village, Sa Tain village tract: “We do not have clinics in the village. If villagers are sick, they have to go to the clinic in Bs--- or Bt--- [villages]. If there is no fighting, it is easy to travel. It’s not easy to travel if there is fighting because we have to pass SAC LIBs #559 and #560 checkpoints at Bs--- when we go to the clinic. If we continue going to Bt---, we have to pass Ta Ta Gyi. There is a big checkpoint. It is not easy to pass that checkpoint. The SAC at the checkpoint asked questions and if you are a villager from Br---, they don’t let you pass because [SAC soldiers think that] armed resistance groups mostly stay in Br---  village. The SAC targeted Br--- villagers as people who support armed resistance groups.”

   Confiscation of medicines:

SAC soldiers at checkpoints not only impede villagers from traveling to certain areas (and make villagers fearful of arrest and torture), but also confiscate their food, medicines and medical supplies. U Dq---, who lives in Bv--- village, Za Yat Gyi Tuang Chan village tract, Htan Ta Pin Township, Taw Oo District, said: “There is no way to transport medicines. They [SAC] did not allow transporting medicines here, so people transport medicines with their nearest connection. The healthcare workers implemented it [transporting medicines] by themselves. If there are financial needs [to cover the costs], the village head and civilians provided it as necessary. That’s how it is done. We faced difficulty with medicines twice [during the period] from 2022 to 2024. It went smoothly on other times. Sometimes, KNU also supported [providing medicines] as they can. Recently, Free Burma Rangers also supported with medical supplies. The treatment is for all, including soldiers and civilians.”

Similarly, the villagers of Bw--- village in the Leh Hka village tract, Ler Doh Township, Kler Lwee Htoo District, faced healthcare challenges as transportation of medicine from the city to the village was prohibited by the SAC. In the village, two individuals have medical knowledge, so villagers from nearby villages like Bx--- and By--- also sought medical care in Bw--- village. Naw Dr---, from Bw--- village, explained: “There is no way to get medicine or go to the hospital because of the conflict, and sometimes Burmese [Burma Army] soldiers interrupt us on our way”. In some instances, the limited medical supplies in Ler Doh Township are rationed by local healthcare workers and kept for those who are severely ill. Although it is necessary for sick people to get treatment in highly equipped medical facilities, like Taw Oo hospital, they dare not go due to the safety and insecurity of travelling through SAC checkpoints. 

     Long distances and inaccessible terrain:

For some villagers, attending hospitals and further medical follow-ups become an extreme difficulty due to the long-distance and ongoing SAC attacks. Some villagers who were injured by SAC artillery fire died while being transported to receive medical treatment. For instance, on July 1st 2024 at about 2:15 pm, SAC LIB #73 fired mortar rounds and two rounds landed on Bz--- village, Mone village tract, Ler Doh Township, Kler Lwee Htoo District. Due to the shelling, five people from the same family were hit. Ma Ae---, a relative, explained: “I heard the sound, and I ran towards it [them]. My brother [Ko Ag---] was already killed. My sister-in-law [Ma Ah---] fell on the ground. My nieces [16-year-old Ma Ai---and 8-year-old Aj---] and my nephew [2-year-old Maung Ak---] were there. […] We had to come to Ca--- clinic [run by CDM doctors] first. It was while people were running from panic, while I was asking for help. It was so delayed. My sister-in-law was killed although she shouldn’t have died. It wasn’t alright to come here because of the difficulty of the road [due to the conflict]. It took an hour to carry [her] and by boat. It took an hour to reach Cb---place. From there, we had to come by car to reach here. It was extremely difficult.” The three siblings were hospitalised in different clinics, and could not keep with all medical follow ups due to the cost of transportation.

A similar situation was reported by Saw Al---, the village head from Cc--- village, Noh Hpoh village tract, Kaw T’Ree Township, Dooplaya District: “In terms of healthcare, there are a few healthcare workers. During the fighting, if people are seriously sick, it’s extremely difficult to go to another country [Thailand] for treatment due to the situation on the way [fighting, air strikes, and shelling]. People have to travel in fear. […] There are no doctors or medicines for the treatment in the village so that they [local healthcare workers] are helping villagers as much as they can.”

Weather conditions in Southeast Burma also pose significant barriers to easily access health-related services, exacerbated by the ongoing SAC attacks and militarisation that create insecurity to use the main, paved roads. Villagers from several villages in Kaw T’Ree and Waw Ray Townships, Dooplaya District, reported facing severe healthcare challenges due to the lack of nearby hospitals. The closest medical facilities are far, and poor road conditions, flooding, and safety concerns difficult the travelling. Villagers resorted to buying medicine from shops for minor illnesses. However, emergency cases, injuries caused by armed attacks, and childbirth supposed critical situations, with some villagers losing their lives due to delays in receiving medical treatment.

On August 7th 2024, at 7:38 pm, SAC LIB #246 shelled four mortar shells, with two landing in Cd--- village, Htoe War Seik village tract, Ler Doh Township, Kler Lwee Htoo District, injuring an 11-year-old girl, Naw Am---. She sustained injuries to her lower arm, abdomen, and back. The girl was sent to Ce--- clinic (administered by the KDHW) for treatment. Saw An---, from Cd--- village, explained: “When we were sending her [Naw Am---], we originally thought that we would go through the way crossing the river by a pulley raft, so that it [the clinic] would be nearer [faster to reach], but it was raining and flooding, so we had to go through another route called Ef---, and it took longer because of the flooding and the road was destroyed. If we go to the General Hospital which belongs to the SAC, it [treatment] would cost a lot. Our KNU leaders helped [built a clinic], so we went to that clinic that does not cost a lot; just through offerings [based on donation].”

Due to the heavy rain and landslides in Day Loh Muh Nu area, Daw Hpah Hkoh Township, Taw Oo District, villagers faced difficulties travelling and buying and transporting things from the town or elsewhere. Similarly, villagers reported flooding of clinics due to heavy rains in Ler Doh Township, Kler Lwee Htoo District, from May to July 2024. The combination of weather-induced clinic closures and the lack of available medicines has forced many villagers to travel long distances to hospitals, straining both their health and financial resources. The rainy season also led to an increase in cases of diarrhea, fever, and malaria, further complicating the healthcare crisis.

d) Displacement leading to an additional crisis 

Villagers have to displace themselves as SAC troops continuously attack their villages, due to ongoing fighting, or given the risk of military attacks. When villagers have to flee, they have to endure harsh conditions that severely affect their health. These living conditions are particularly difficult for children, elderly people, and pregnant women, because of unavailability of medicines and specialised healthcare.

For instance, due to the SAC shelling starting from December 2023, and ongoing in January 2024, in Bn--- village, Kaw Ler village tract, Tha Htoo Township, Doo Tha Htoo District, villagers from Bn--- village and other villages in Tha Htoo Township fled to Tha Htoo (Tha Hton) Town, to Eg--- Town (in Thailand), and to Co--- cave. Saw Z---, a displaced villager from Bn--- village, expressed: “One senior monk from Cg--- village came to us and donated drinking water. We face extreme cold in this cave, and it impacted [our health] because we usually do not live in cold areas like this. […] Some villagers are sick, so we asked Kawthoolei [KDHW] health workers to come and help us [providing medical treatment]. […] Running noses and coughing are common illnesses. […] Some villagers experienced diarrhoeas the first couple days we fled here.”

During the rainy season, displaced villagers were also severely impacted by poor sheltering and lack of access to healthcare. In Mu Traw District, a village head from Cj--- village, Meh Klaw village tract, Bu Tho Township, named Saw Ap---, explained: “Those displaced by the water source need tarpaulins. They said it would be better to have tarpaulins because they can lie down and cover [their] sides using tarpaulins and sleep. […] They need mosquito nets and all sorts of things to prevent being bitten by mosquitoes and insects. […] The teacher told me that students are being bitten by mosquitoes and insects while they are studying in the jungle. Some children are infected by malaria.” He added: 

“There was a pregnant woman who gave birth. If the situation was like before, we could go to the healthcare workers. She would have received medicines or get vaccine” 

Saw Ap--- had been displaced for three years in the jungle since the SAC air attacks happened on his village area on 2021.

Often, displaced villagers do not have access to healthcare workers. Naw Dj---, a 56-year-old villager from Ck--- village, Meh Nyoo village tract, Bu Tho Township, Mu Traw District, who was displaced to the forest due to fighting, as well as SAC air strikes and shelling starting from March 28th 2024, explained: “We sought treatment from the healthcare workers who were staying at the cave. If we could reach them, we would get medicines. If we couldn’t, we just had to endure the suffering. […] This year [2024], people from every household suffered from measles. Some were seriously affected, while others were alright. Those who were seriously affected experienced redness on their faces. Every household was impacted —it affected the entire [displaced] village.” 

During displacement, villagers remain afraid of SAC attacks. A villager named Naw Dl---, from Cm--- village, Meh Klaw village tract, Bu Tho Township, Mu Traw District, highlighted: “There are so many challenges. My youngest child is sick, and we are in the jungle without access to medicine. We are worried because the hospital is far away […]. We are unable to do much, not even cook rice. The other night, we didn’t get to eat rice.” Another villager from the same village, Naw Dm---, reported: “The children are crying. Pregnant women who give birth have to stay at other people’s houses. Some said they are afraid to light a fire [to avoid being seen by SAC] and had to give birth during the night. Some pregnant women gave birth on the way while fleeing, delivering their babies as they were sent to a specific shelter. It is extremely difficult.”

Narrating the needs during displacement, villagers stressed the urgent necessity of medicines and support. The local coordinated response, formed by local ethnic service providers and community-based organisations, continued to deliver essential supplies to displaced communities, including medicines. In some areas, displaced villagers can also access treatment at clinics run by CDM doctors, or mobile clinics run by the BPWHT. Similarly, villagers also help each other and support displaced villagers. Local authorities also strived to cover protection gaps amidst the conflict –and many local villagers expressed their desires for the KNU to strengthen their support.

e) Lack of mental health services and support 

The ongoing armed conflict has had a devastating impact on local villagers’ wellbeing, leading to significant psychological distress. The destruction of their homes and belongings, coupled with the relentless heavy artillery fire and air strikes conducted by the SAC, has exacerbated mental health issues.[35] Saw Z---, a displaced villager from Bn--- village, Kaw Ler village tract, Tha Htoo Township, Doo Tha Htoo District, explained: 

“Some women have been suffering from heart problems [emotional distress] so they could not handle to hear the sound of mortar explosions. Not only women, but also many children have heart problems [emotional distress] because they will run, scream, cry and even become unconscious when hearing the sound of mortar explosion.”

Villagers also reported mental suffering after witnessing distressing injuries, the loss of loved ones, or the destruction of their belongings, caused by SAC attacks. Due to the air strikes that happened on Khaw Hpoh Pleh village tract, Bilin Township, Doo Tha Htoo District, in March 2024 and in May 2024, villagers from the area displaced to the forest reported suffering mental health problems. Saw Dn---from Cn--- village, P’Ya Raw village tract, Bilin Township, Doo Tha Htoo Township expressed: “After their houses burned because of the air strikes, they seem like their brains are disordered [facing mental health issues]. […] If you try to talk to them, they do not even respond to you for a while [not immediately].” [36]

Reportedly, despite efforts by some local organisations, like KDHW and women’s groups, to address the mental health needs of villagers and those suffering from psychological illnesses, support remains extremely limited. The ongoing conflict makes it challenging to reach and visit patients in conflict-affected areas consistently. Healthcare workers operating on the ground are also experiencing mental and emotional distress due to the constant threat of air strikes and other attacks.[37]

4. Security and legal analysis: SAC attacks on civilians and the right to health

SAC air strikes and shelling on civilian areas since the 2021 coup are causing death and injuries to villagers, attempting against their safety, health, and wellbeing. Ongoing SAC attacks on villages also pose significant barriers to adequate healthcare access for villagers, especially children, the elderly, and pregnant women, who cannot obtain medical treatment safely in their village. Local villagers have struggled to receive care because hospitals and clinics are often rendered inoperable by SAC attacks. SAC military operations and attacks have disrupted villagers’ access to health care by directly impacting providers and medical facilities. Healthcare workers are sometimes displaced along with villagers, making it impossible to reach those in need. Some of these workers have also faced threats from the SAC when carrying medicines and providing services, putting their lives at risk and leading to a lack of healthcare workers. Medicine shortages due to SAC confiscation and ongoing armed conflict add to this healthcare crisis. As a consequence of the worsening situation, treatment costs have also increased exponentially, making healthcare unaffordable for many.

Villagers resort to herbal medicines or traveling to Thailand due to the lack of formal healthcare services. Ongoing attacks and hardships contribute to mental health issues and heightened health risks, for which there is no adequate support. Despite these difficulties, local leaders, community-based and humanitarian organisations, and fellow villagers strive to deliver lifesaving aid and services to all communities in Southeast Burma, although many gaps remain.

The right to health is a fundamental human right recognised under international legal frameworks, including the Universal Declaration of Human Rights, which affirms everyone’s right to a standard of living adequate for health and well-being.[38] It is also codified in the International Covenant on Economic, Social and Cultural Rights (ICESCR), which obligates states to ensure the highest attainable standard of physical and mental health for their population.[39] This right includes access to timely, acceptable, and affordable healthcare. Burma(/Myanmar) has ratified the ICESCR, meaning it is bound to protect and promote people’s access to healthcare.

Access to healthcare during times of conflict is especially paramount, with the rules of customary International Humanitarian Law (IHL) outlining protections for medical personnel and facilities.[40] Attacks from the SAC which targeted medical facilities happened in violation of customary IHL, as healthcare facilities such as hospitals and clinics are protected during armed conflict, only losing their protection when they “commit acts harmful to the enemy”, such as storing arms or munitions.[41] The SAC’s attacks on healthcare facilities not only undermine the provision of essential medical care but also contravene the fundamental protections afforded to medical facilities and personnel under IHL.[42] Attacks against hospitals during conflict are also among the six grave violations identified and condemned by the UN Security Council in their quest to end abuses suffered by children in times of war.[43]

Customary IHL states that parties to a conflict must allow for the passage of humanitarian relief, which includes medical supplies, to civilians in need.[44] The unrelenting attacks from the SAC and the confiscation of medicines and food at checkpoints make it impossible for medical supplies to be safely transported in rural areas in Southeast Burma. Customary IHL also establishes that medical personnel are to be protected in all circumstances during times of armed conflict.[45] These individuals must be safeguarded, unless they engage in harmful acts outside their humanitarian role, to ensure they can perform their vital work safely and uphold medical neutrality in conflict zones. Evidence presented in this briefing paper shows that the SAC continue to attack medical personnel and humanitarian workers in rural areas.

Under international criminal law, intentionally directing attacks against hospitals and places where the sick and wounded are collected may constitute a war crime under Article 8(2)(e)(iv) of the Rome Statute.[46]

5. Recommendations

To international stakeholders, non-governmental organisations (NGOs), local leaders, and regional and foreign governments:

• Increase support to local civil society and community-based organisations ((CSOs/CBOs) and ethnic service providers who are currently assisting villagers to recover from, and cope with, the severe impacts of SAC attacks. 
• Provide adequate healthcare facilities, accessories, and medicines through local organisations working on healthcare provision and offer free healthcare assistance to villagers in need. Ensure specialised support is available for the elderly, pregnant women, infants, and people with disabilities. 
• Ensure that health interventions are implemented through discussion and collaboration with local communities, the Karen Department of Health and Welfare (KDHW), and community-based healthcare providers to effectively implement culturally appropriate and non-discriminatory health services.
• Continue to increase funding to healthcare, especially maternal and antimalarial healthcare, including through the KDHW and community-based healthcare providers, particularly in rural ethnic areas, to ensure that healthcare services and facilities are available and accessible to all villagers in Southeast Burma.
• Ensure that landmine victims and other persons whose health has been severely affected by conflict and abuse have access to free medical care. Humanitarian and development actors should assist in providing funding and building their capacity to ensure free quality healthcare for all victims.
• Increase funding and resources for local healthcare organisations to expand mental health services. This includes training more mental health professionals and volunteers to provide timely and consistent support. Additionally, develop and deploy mobile mental health units to reach remote and conflict-affected areas and ensure that patients receive care despite the ongoing conflict.
• Impose a comprehensive arms embargo on Burma/Myanmar and implement extensive sanctions on the supply of arms and military material to the Myanmar military including aviation fuel, aircraft, aircraft parts, maintenance supplies, munitions, technologies, training or other technical assistance or services. 
• Implement further coordinated and targeted sanctions on oil and gas revenues, as well as sanctions against junta officials to undermine their ability to finance their attacks on civilians.
• Support and broaden the scope of international investigations to include human rights violations against the Karen people, and hold the SAC accountable for its crimes against civilians in Burma by prosecuting SAC leaders in international courts, including the International Criminal Court (ICC), and through universal jurisdiction proceedings.

Front cover photo note: 
This photo was taken in August 2024 at a KNU-administered clinic in Hein Thar Wel village tract, Ler Doh (Kyaukkyi) Township, Kler Lwee Htoo District. The photo shows a girl who had just arrived at the clinic for treatment, after she sustained injuries from indiscriminate shelling conducted by the State Administration Council (SAC) on August 7th 2024 into Cd--- village, Htoo Wah Seh village tract, Ler Doh Township. [Photo: KHRG]